An Act

ENROLLED HOUSE
BILL NO. 2962                       By: Nelson, Denney, Kannady,
                                        Dunnington, Henke,
                                        Montgomery, Sherrer,
                                        McDaniel (Jeannie), Brown,
                                        Kouplen, Condit, Perryman,
                                        Cleveland, McBride, Casey,
                                        Roberts (Dustin), Kirby,
                                        Virgin, Rousselot, Cooksey,
                                        Lockhart, Cannaday, Stone,
                                        Murdock, Inman, Shelton,
                                        Griffith, Ownbey, Vaughan,
                                        Wallace, Fisher, Munson,
                                        Christian, Echols, Nollan,
                                        Wood, Loring, Bennett,
                                        Renegar, Lepak, Hoskin,
                                        Martin and Morrissette of
                                        the House

                                                and

                                        Griffin, Boggs, Thompson,
                                        Bass, David, Simpson,
                                        Crain, Matthews, Brooks,
                                        Fields, Bice, Floyd,
                                        Dossett and Pittman of the
                                        Senate




       An Act relating to autism spectrum disorders;
       requiring certain coverage for certain treatments;
       specifying age and coverage limitations; prohibiting
       termination or refusal of coverage for certain
       reasons; stipulating limitations; providing certain
       construction; specifying maximum benefits under
       certain coverage; directing Oklahoma Insurance
       Commissioner to annually adjust certain limits;
       excluding certain payments from certain calculation;
       mandating inclusion of certain services; permitting
       insurers to review treatment plans; providing certain
       applications; requiring certain costs be borne by
       insurer; providing certain exceptions; providing
       definitions; directing certain agencies to conduct
       certain examination; requiring certain report;
       directing Oklahoma Health Care Authority to submit
       certain documents under certain circumstances;
       providing limitations; providing definitions;
       amending 36 O.S. 2011, Section 6060.20, which relates
       to mandated coverage; deleting certain construction;
       providing exemptions under certain circumstances;
       specifying certain calculation; providing guidelines
       for issuance of exemptions; providing for
       codification; and providing an effective date.




SUBJECT:   Autism spectrum disorders

BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:

    SECTION 1.     NEW LAW     A new section of law to be codified
in the Oklahoma Statutes as Section 6060.21 of Title 36, unless
there is created a duplication in numbering, reads as follows:

    A. For all plans issued or renewed on or after November 1,
2016, a health benefit plan and the Oklahoma Employees Health
Insurance Plan shall provide coverage for the screening, diagnosis
and treatment of autism spectrum disorder in individuals less than
nine (9) years of age, or if an individual is not diagnosed or
treated until after three (3) years of age, coverage shall be
provided for at least six (6) years, provided that the individual
continually and consistently shows sufficient progress and
improvement as determined by the health care provider. No insurer
shall terminate coverage, or refuse to deliver, execute, issue,
amend, adjust or renew coverage to an individual solely because the
individual is diagnosed with or has received treatment for an autism
spectrum disorder.

    B. Except as provided in subsection E of this section, coverage
under this section shall not be subject to any limits on the number
of visits an individual may make for treatment of autism spectrum
disorder.

    C. Coverage under this section shall not be subject to dollar
limits, deductibles or coinsurance provisions that are less


ENR. H. B. NO. 2962                                            Page 2
favorable to an insured than the dollar limits, deductibles or
coinsurance provisions that apply to substantially all medical and
surgical benefits under the health benefit plan, except as otherwise
provided in subsection E of this section.

    D. This section shall not be construed as limiting benefits
that are otherwise available to an individual under a health benefit
plan.

    E. Coverage for applied behavior analysis shall be subject to a
maximum benefit of twenty-five (25) hours per week and no more than
Twenty-five Thousand Dollars ($25,000.00) per year. Beginning
January 1, 2018, the Oklahoma Insurance Commissioner shall, on an
annual basis, adjust the maximum benefit for inflation by using the
Medical Care Component of the United States Department of Labor
Consumer Price Index for All Urban Consumers (CPI-U). The
Commissioner shall submit the adjusted maximum benefit for
publication annually before January 1, 2018, and before the first
day of January of each calendar year thereafter, and the published
adjusted maximum benefit shall be applicable in the following
calendar year to the Oklahoma Employees Health Insurance Plan and
health benefit plans subject to this section. Payments made by an
insurer on behalf of a covered individual for treatment other than
applied behavior analysis shall not be applied toward any maximum
benefit established under this section.

    F. Coverage for applied behavior analysis shall include the
services of the board-certified behavior analyst or a licensed
doctoral-level psychologist.

    G. Except for inpatient services, if an insured is receiving
treatment for an autism spectrum disorder, an insurer shall have the
right to review the treatment plan annually, unless the insurer and
the insured's treating physician or psychologist agree that a more
frequent review is necessary. Any such agreement regarding the
right to review a treatment plan more frequently shall apply only to
a particular insured being treated for an autism spectrum disorder
and shall not apply to all individuals being treated for autism
spectrum disorder by a physician or psychologist. The cost of
obtaining any review or treatment plan shall be borne by the
insurer.

    H. This section shall not be construed as affecting any
obligation to provide services to an individual under an



ENR. H. B. NO. 2962                                           Page 3
individualized family service plan, an individualized education
program or an individualized service plan.

    I. Nothing in this section shall apply to nongrandfathered
plans in the individual and small group markets that are required to
include essential health benefits under the federal Patient
Protection and Affordable Care Act, Public Law 111-148, or to
Medicare supplement, accident-only, specified disease, hospital
indemnity, disability income, long-term care or other limited
benefit hospital insurance policies.

    J.   As used in this section:

    1. "Applied behavior analysis" means the design, implementation
and evaluation of environmental modifications, using behavioral
stimuli and consequences, to produce socially significant
improvement in human behavior, including the use of direct
observation, measurement and functional analysis of the relationship
between environment and behavior;

    2. "Autism spectrum disorder" means any of the pervasive
developmental disorders or autism spectrum disorders as defined by
the most recent edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM) or the edition that was in effect at the time
of diagnosis;

    3. "Behavioral health treatment" means counseling and treatment
programs, including applied behavior analysis, that are:

         a.   necessary to develop, maintain or restore, to the
              maximum extent practicable, the functioning of an
              individual, and

         b.   provided by a board-certified behavior analyst or by a
              licensed doctoral-level psychologist so long as the
              services performed are commensurate with the
              psychologist's university training and experience;

    4. "Diagnosis of autism spectrum disorder" means medically
necessary assessment, evaluations or tests to diagnose whether an
individual has an autism spectrum disorder;

    5. "Health benefit plan" means any plan or arrangement as
defined in subsection C of Section 6060.4 of Title 36 of the
Oklahoma Statutes;


ENR. H. B. NO. 2962                                             Page 4
    6. "Oklahoma Employees Health Insurance Plan" means "Health
Insurance Plan" as defined in Section 1303 of Title 74 of the
Oklahoma Statutes;

    7. "Pharmacy care" means medications prescribed by a licensed
physician and any health-related services deemed medically necessary
to determine the need or effectiveness of the medications;

    8. "Psychiatric care" means direct or consultative services
provided by a psychiatrist licensed in the state in which the
psychiatrist practices;

    9. "Psychological care" means direct or consultative services
provided by a psychologist licensed in the state in which the
psychologist practices;

    10. "Therapeutic care" means services provided by licensed or
certified speech therapists, occupational therapists or physical
therapists; and

    11. "Treatment for autism spectrum disorder" means evidence-
based care and related equipment prescribed or ordered for an
individual diagnosed with an autism spectrum disorder by a licensed
physician or a licensed doctoral-level psychologist who determines
the care to be medically necessary, including, but not limited to:

        a.   behavioral health treatment,

        b.   pharmacy care,

        c.   psychiatric care,

        d.   psychological care, and

        e.   therapeutic care.

    SECTION 2.     NEW LAW     A new section of law to be codified
in the Oklahoma Statutes as Section 1011.12 of Title 56, unless
there is created a duplication in numbering, reads as follows:

    A. The Oklahoma Health Care Authority, in conjunction with the
Department of Mental Health and Substance Abuse Services, the State
Department of Health and the State Department of Education shall
examine the feasibility of a state plan amendment to the Oklahoma


ENR. H. B. NO. 2962                                           Page 5
Medicaid Program for applied behavior analysis treatment of autism
spectrum disorders.

    B. On or before December 31, 2016, the Authority and partnering
agencies shall submit a report to the President Pro Tempore of the
Senate, the Speaker of the House of Representatives and the Governor
estimating the potential costs to the state, clinical findings,
reviews of pilot projects and research from other states on the
effects of applied behavioral analysis treatment on autism spectrum
disorders.

    C. Beginning July 1, 2017, and subject to the availability of
funding, the Authority and partnering agencies shall draft a state
plan amendment for applied behavior analysis treatment of autism
spectrum disorders. The provisions of this subsection shall only
apply if the report required by subsection B of this section
demonstrates applied behavioral analysis treatment to be evidence-
based and essential to qualifying participants in the Oklahoma
Medicaid Program.

    D.   As used in this section:

    1. "Applied behavior analysis" means the design, implementation
and evaluation of environmental modifications, using behavioral
stimuli and consequences, to produce socially significant
improvement in human behavior, including the use of direct
observation, measurement and functional analysis of the relationship
between environment and behavior;

    2. "Autism spectrum disorder" means any of the pervasive
developmental disorders or autism spectrum disorders as defined by
the most recent edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM) or the edition that was in effect at the time
of diagnosis;

    3. "Behavioral health treatment" means counseling and treatment
programs, including applied behavior analysis, that are:

         a.   necessary to develop, maintain or restore, to the
              maximum extent practicable, the functioning of an
              individual, and

         b.   provided by a board-certified behavior analyst or by a
              licensed doctoral-level psychologist so long as the
              services performed are commensurate with the


ENR. H. B. NO. 2962                                           Page 6
             psychologist's university training and supervised
             experience; and

    4. "Treatment for autism spectrum disorder" means evidence-
based care and related equipment prescribed or ordered for an
individual diagnosed with an autism spectrum disorder by a licensed
physician or a licensed doctoral-level psychologist who determines
the care to be medically necessary, including, but not limited to:

        a.   behavioral health treatment,

        b.   pharmacy care,

        c.   psychiatric care,

        d.   psychological care, and

        e.   therapeutic care.

    SECTION 3.     AMENDATORY    36 O.S. 2011, Section 6060.20, is
amended to read as follows:

    Section 6060.20 A. All individual and group health insurance
policies that provide medical and surgical benefits shall provide
the same coverage and benefits to any individual under the age of
eighteen (18) years who has been diagnosed with an autistic disorder
as it would provide coverage and benefits to an individual under the
age of eighteen (18) years who has not been diagnosed with an
autistic disorder.

    B. As used in this section, "autistic disorder" means a
neurological disorder that is marked by severe impairment in social
interaction, communication, and imaginative plan play, with onset
during the first three (3) years of life and is included in a group
of disorders known as autism spectrum disorders.

    C. Nothing in this section shall be construed to require an
insurer to provide any benefits for the diagnosis or treatment of
any autistic disorder.

    SECTION 4.     NEW LAW     A new section of law to be codified
in the Oklahoma Statutes as Section 6060.22 of Title 36, unless
there is created a duplication in numbering, reads as follows:




ENR. H. B. NO. 2962                                           Page 7
    A. 1. A health benefit plan that, at the end of its base
period, experiences a greater than one percent (1%) increase in
premium costs pursuant to providing applied behavior analysis for
treatment of autism spectrum disorders shall be exempt from the
provisions of this act.

    2. To calculate base-period-premium costs, the health benefit
plan shall subtract from premium costs incurred during the base
period, both the premium costs incurred during the period
immediately preceding the base period and any premium cost increases
attributable to factors unrelated to benefits for treatment of
autism spectrum disorders.

    3.   a.      To claim the exemption provided for in subsection A of
                 this section a health benefit plan shall provide to
                 the Insurance Commissioner a written request signed by
                 an actuary stating the reasons and actuarial
                 assumptions upon which the request is based.

          b.     The Commissioner shall verify the information provided
                 and shall approve or disapprove the request within
                 thirty (30) days of receipt.

          c.     If, upon investigation, the Commissioner finds that
                 any statement of fact in the request is found to be
                 knowingly false, the health benefit plan may be
                 subject to suspension or loss of license or any other
                 penalty as determined by the Commissioner, or the
                 State Commissioner of Health with regard to health
                 maintenance organizations.

    SECTION 5.    This act shall become effective November 1, 2016.




ENR. H. B. NO. 2962                                              Page 8
    Passed the House of Representatives the 27th day of April, 2016.




                                    Presiding Officer of the House
                                                of Representatives


    Passed the Senate the 14th day of April, 2016.




                                   Presiding Officer of the Senate


                       OFFICE OF THE GOVERNOR

    Received by the Office of the Governor this ____________________

day of ___________________, 20_______, at _______ o'clock _______ M.

By: _________________________________

    Approved by the Governor of the State of Oklahoma this _________

day of ___________________, 20_______, at _______ o'clock _______ M.



                                   _________________________________
                                   Governor of the State of Oklahoma


                  OFFICE OF THE SECRETARY OF STATE

    Received by the Office of the Secretary of State this __________

day of ___________________, 20_______, at _______ o'clock _______ M.

By: _________________________________




ENR. H. B. NO. 2962                                           Page 9